Does ovarian hyperstimulation in intrauterine insemination for cervical factor subfertility improve pregnancy rates?

Background: Intrauterine insemination (IUI) can be performed with or without controlled ovarian hyperstimulation (COH). Studies in which the additional benefit of COH on IUI for cervical factor subfertility is assessed are lacking. We assessed whether COH in IUI improved pregnancy rates in cervical factor subfertility. Methods: We performed a historical cohort study among couples with cervical factor subfertility, treated with IUI. A cervical factor was diagnosed by a well-timed, non-progressive post-coital test with normal semen parameters. We compared ongoing pregnancy rate per cycle in groups treated with IUI with or without COH. We tabulated ongoing pregnancy rates per cycle number and compared the effectiveness of COH by stratified univariable analysis. Results: We included 181 couples who underwent 330 cycles without COH and 417 cycles with COH. Ongoing pregnancy rates in IUI cycles without and with COH were 9.7% and 12.7%, respectively (odds ratio 1.4; 95% confidence interval 0.85-2.2). The pregnancy rates in IUI without COH in cycles 1, 2, 3 and 4 were 14%, 11%, 6% and 15%, respectively. For IUI with COH, these rates were 17%, 15%, 14% and 16%, respectively. Conclusions: Although our data indicate that COH improves the pregnancy rate over IUI without COH, IUI without COH generates acceptable pregnancy rates in couples with cervical factor subfertility. Since IUI without COH bears no increased risk for multiple pregnancy, this treatment should be seriously considered in couples with cervical factor subfertility

Clinical characteristics of women captured by extending the definition of severe postpartum haemorrhage with 'refractoriness to treatment': a cohort study

Background: The absence of a uniform and clinically relevant definition of severe postpartum haemorrhage hampers comparative studies and optimization of clinical management. The concept of persistent postpartum haemorrhage, based on refractoriness to initial first-line treatment, was proposed as an alternative to common definitions that are either based on estimations of blood loss or transfused units of packed red blood cells (RBC). We compared characteristics and outcomes of women with severe postpartum haemorrhage captured by these three types of definitions. Methods: In this large retrospective cohort study in 61 hospitals in the Netherlands we included 1391 consecutive women with postpartum haemorrhage who received either ≥4 units of RBC or a multicomponent transfusion. Clinical characteristics and outcomes of women with severe postpartum haemorrhage defined as persistent postpartum haemorrhage were compared to definitions based on estimated blood loss or transfused units of RBC within 24 h following birth. Adverse maternal outcome was a composite of maternal mortality, hysterectomy, arterial embolisation and intensive care unit admission. Results: One thousand two hundred sixty out of 1391 women (90.6%) with postpartum haemorrhage fulfilled the definition of persistent postpartum haemorrhage. The majority, 820/1260 (65.1%), fulfilled this definition within 1 h following birth, compared to 819/1391 (58.7%) applying the definition of ≥1 L blood loss and 37/845 (4.4%) applying the definition of ≥4 units of RBC. The definition persistent postpartum haemorrhage captured 430/471 adverse maternal outcomes (91.3%), compared to 471/471 (100%) for ≥1 L blood loss and 383/471 (81.3%) for ≥4 units of RBC. Persistent postpartum haemorrhage did not capture all adverse outcomes because of missing data on timing of initial, first-line treatment. Conclusion: The definition persistent postpartum haemo

Artificial insemination: intrauterine insemination

Artificial insemination has been used to treat infertility since the eighteenth century, and continues to be commonly performed. This chapter explores the medical indications for use of artificial insemination and provides evidence-based recommendations for therapeutic use. © Springer Science+Business Media, LLC 2010.Pieternel Steures, Ben W. J. Mol, Fulco van der Vee

History of induced abortion and the risk of tubal pathology

Tubal pathology is a common cause of subfertility. Identifying risk factors for tubal pathology in the medical history is important to distinguish between those couples who benefit from early tubal patency tests and those in whom presence of tubal pathology is less likely and delaying tubal tests is justified. This study evaluated whether a medical history of induced abortion is associated with an increased risk of tubal disease among subfertile couples. The reproductive history was determined for each couple. Tubal disease was diagnosed by hysterosalpingography and/or diagnostic laparoscopy. The association between reproductive history and the presence of tubal disease was assessed by calculating odds ratios (OR) and 95% confidence intervals (CI). Data from 6149 couples were available for analysis. The OR for tubal pathology after a previous induced abortion was 1.6 (95% CI 1.3 to 1.9), after a previous ectopic pregnancy, 8.4 (95% CI 6.3 to 12), after a previous spontaneous miscarriage, 1.1 (95% CI 0.87 to 1.3), and after a previous live birth, 1.0 (95% CI 0.88 to 1.2). A history of induced abortion is associated with an increased risk of tubal pathology in subfertile couples. As a consequence, in subfertile women with a history of induced abortion, tubal patency tests should be considered early in the diagnostic work-up.HR Verhoeve, P Steures, PA Flierman, F van der Veen, BWJ Mo

Long-term outcome in couples with unexplained subfertility and an intermediate prognosis initially randomized between expectant management and immediate treatment

BACKGROUND We recently reported that treatment with intrauterine insemination and controlled ovarian stimulation (IUI-COS) did not increase ongoing pregnancy rates compared with expectant management (EM) in couples with unexplained subfertility and intermediate prognosis of natural conception. Long-term cost-effectiveness of a policy of initial EM is unknown. We investigated whether the recommendation not to treat during the first 6 months is valid, regarding the long-term effectiveness and cumulative costs. METHODS Couples with unexplained subfertility and intermediate prognosis of natural conception (n=253, at 26 public clinics, the Netherlands) were randomly allocated to 6 months EM or immediate start with IUI-COS. The couples were then treated according to local protocol, usually IUI-COS followed by IVF. We followed couples until 3 years after randomization and registered pregnancies and resources used. Primary outcome was time to ongoing pregnancy. Secondary outcome was treatment costs. Analysis was by intention-to-treat. Economic evaluation was performed from the perspective of the health care institution. RESULTS Time to ongoing pregnancy did not differ between groups (log-rank test P=0.98). Cumulative ongoing pregnancy rates were 72–73% for EM and IUI-COS groups, respectively [relative risk 0.99 (95% confidence interval (CI) 0.85–1.1)]. Estimated mean costs per couple were €3424 (95% CI €880–€5968) in the EM group and €6040 (95% CI €4055–€8125) in the IUI-COS group resulting in an estimated saving of €2616 per couple (95% CI €385–€4847) in favour of EM. CONCLUSIONS In couples with unexplained subfertility and an intermediate prognosis of natural conception, initial EM for 6 months results in a considerable cost-saving with no delay in achieving pregnancy or jeopardizing the chance of pregnancy. Further comparisons between aggressive and milder forms of ovarian stimulation should be performed.Inge M. Custers, Minouche M.E. van Rumste, Jan Willem van der Steeg, Madelon van Wely, Peter G.A. Hompes, Patrick Bossuyt, Frank J. Broekmans, Cees N.M. Renckens, Marinus J.C. Eijkemans, Thierry J.H.M. van Dessel, Fulco van der Veen, Ben W.J. Mol, Pieternel Steures, and CECER

Reproducibility and reliability of repeated semen analyses in male partners of subfertile couples

Presented in part at the 65th Annual Meeting of the American Society for Reproductive Medicine, Atlanta, Georgia, October 17–21, 2009.Abstract not availableEsther Leushuis, Jan Willem van der Steeg, Pieternel Steures, Sjoerd Repping, Patrick M.M. Bossuyt, Marinus A. Blankenstein, Ben Willem J. Mol, Fulco van der Veen, and Peter G.A. Hompe

Couples dropping out of a reimbursed intrauterine insemination program: what is their prognostic profile and why do they drop out?

ObjectiveTo evaluate whether baseline characteristics and prognostic profiles differed between couples who drop out from intrauterine insemination (IUI) and couples that continue IUI, and the reasons for couples dropping out from IUI programs.DesignRetrospective observational cohort study.SettingFertility centers.Patient(s)Consecutive subfertile couples undergoing IUI.Intervention(s)None.Main outcome measure(s)Characteristics and prognosis of ongoing pregnancy after IUI at the start of treatment of couples that dropped out compared with couples that continued treatment or achieved an ongoing pregnancy.Result(s)We studied 803 couples who underwent 3,579 IUI cycles of whom 221 couples dropped out (28%). Couples dropping out completed 2.8 (SD ±1.4) cycles per couple compared with 4.5 (SD ±2.3) cycles per couple for those continuing treatment. Couples dropping out had a higher female age, longer subfertility duration, and higher basal FSH. Mean prognosis to achieve an ongoing pregnancy after IUI at start of treatment was 7.9% (SD ±2.4) per cycle for couples who dropped out and 8.5% (SD ±2.5) per cycle for couples continuing treatment. Of the dropouts, 100 couples (45%) were actively censored from the IUI program, 87 couples (39%) because of poor prognosis; 121 couples (55%) were passively censored from the program, of whom 62 (28%) dropped out owing to personal reasons; 59 couples (27%) were lost to follow-up.Conclusion(s)We found significant differences in prognostic profile between couples continuing treatment and couples dropping out, although these differences seem limited from a clinical perspective. We conclude that overestimation of ongoing pregnancy rates after IUI due to couples dropping out is limited.Inge M. Custers, Thierry H. J. H. M. van Dessel, Paul A. Flierman, Pieternel Steures, Madelon van Wely, Fulco van der Veen, and Ben W. J. Mo